Provider Demographics
NPI:1295318335
Name:SLACK, GRANT M (MD)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:M
Last Name:SLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 RIX MILLS RD
Mailing Address - Street 2:
Mailing Address - City:NEW CONCORD
Mailing Address - State:OH
Mailing Address - Zip Code:43762-3500
Mailing Address - Country:US
Mailing Address - Phone:740-630-8881
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-1200
Practice Address - Country:US
Practice Address - Phone:304-598-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program